A clinician's approach to lacrimal disorders should be logical and
organized. Just as neurologic disorders must be carefully localized, so
too should lacrimal problems be correctly localized and diagnosed before
treatment is implemented. A thorough evaluation of the lacrimal
drainage system should begin with the eyes, eyelids, and puncta and terminate
with the distal nasolacrimal duct and intranasal passages. Haphazard
trial-and-error therapies are to be avoided.

This chapter is organized into basic sections on anatomy, physiology, pathology/pathophysiology, diagnosis, and treatment. The content of these
sections emphasizes clinically relevant material to aid in understanding, diagnosing, and
treating lacrimal disorders.

“Watery eyes” are among the most common lacrimal symptoms. Patients
with this symptom have one of two problems: either they produce
too many tears (hypersecretion) or the tears that are produced cannot
properly drain (epiphora). Through the understanding of relevant lacrimal
anatomy, physiology, pathology/pathophysiology, and diagnostic
techniques (none more important than history), a clinician can make such
very basic and very important distinctions in patients with watery
eyes. The material presented in this chapter thoroughly addresses disorders
of the lacrimal drainage system, such as the watery eyes example, and
offers clinicians a logical, orderly approach.

An understanding of the anatomic elements of the lacrimal drainage system
is necessary to appreciate the operation of the system and how different
diseases can affect its function. These elements include the bony
conduit, the membranous conduit, and the surrounding soft tissues, tendons, and
muscles.

BONY CONDUIT

Within the nasofrontal process of the maxilla at the anterior nasal portion
of the orbit is the lacrimal fossa, in which is found the lacrimal
sac. From there, the nasolacrimal canal, which contains the nasolacrimal
duct, extends down inside the lateral wall of the nose and opens
under the inferior turbinate or concha in the vault of the meatus of the
turbinate. The nasolacrimal canal is approximately 16 mm posterior
from the anterior tip of the turbinate and is located between the anterior
third and the middle third of the meatus of the turbinate. It exits
in the vault of the meatus of the turbinate 17 mm above the floor of
the nose laterally. There are, however, normal variations in which the
end of the nasolacrimal canal can extend farther down and open at various
positions in the lateral wall of the nose. The lacrimal sac fossa
is present in the anterior-inferior nasal portion of the bony orbit
and is delineated anteriorly by the anterior lacrimal crest and posteriorly
by the posterior lacrimal crest. If viewed from the inside of the
nose, it would be outlined on the lateral wall of the nose in front
of the anterior tip of the middle turbinate (Fig. 1). The nasolacrimal canal is not vertical in direction but angulates posteriorly 15 degrees
and slightly inward almost 5 degrees to reach its
final destination under the inferior turbinate (Fig. 2). Two sinuses are in intimate relationship with the lacrimal bony conduit, the
maxillary sinus or antrum, which forms the lateral wall of the
nose in that area, and the ethmoidal sinus, which borders the posterior
edge of the lacrimal sac fossa and the superior nasolacrimal duct. The
ethmoidal sinus is a system of mucous membrane-lined air cells that
are positioned immediately posterior to the lacrimal sac fossa and
the lacrimal bone. It is not uncommon (as many as 80% to 90% of patients),1 however, for the ethmoidal air cells to encroach in various degrees into
the bone at the posterior lacrimal crest; in some cases, they actually
extend as far as the anterior lacrimal crest area separating the lacrimal
sac from the lateral wall of the nose and intranasal cavity (Fig. 3). Also, the anterior tip of the middle turbinate may extend various degrees
anteriorly into the intranasal cavity. These anatomic variations
become important considerations when lacrimal surgical procedures are
necessary.

Fig. 1. Outline of the lacrimal sac fossa and nasolacrimal duct in its course under
the inferior turbinate as viewed inside the nose looking at the lateral
wall of the nose.

Fig. 2. Frontal view of the nasolacrimal duct and its course.

Fig. 3. Axial view of the normal relationship of the lacrimal sac fossa, the ethmoidal
air cells, and the tip of the middle turbinate, with variations
that may be encountered.

MEMBRANOUS CONDUIT

Dimensions

Contained within the bony conduit and the nasal portion of the eyelids
are the epithelium-lined tear ducts through which tears pass from the
eyelids into the nose. The openings of this membranous conduit in the
eyelids are the upper and lower puncta, which are located 6 mm from the
inner canthus. The punctal openings in the eyelid are 0.3 mm in diameter. The
canalicular portion just beyond the punctum is called the ampulla. It is vertically oriented for 2 mm and balloons out to a diameter of 2.5 mm (Fig. 4). The canaliculi then narrow to about 1 mm in diameter and extend nasally 8 mm
to enter the lacrimal sac. In more than 90% of people, the canaliculi
join before entering the sac at the level of the lower border
of the medial canthal tendon. The tear sac itself is 12 to 15 mm in vertical
length, and in most instances there is a portion above the entrance
of the common canaliculus 3 to 4 mm in height called the fundus (dome), which is usually compressed by the medial canthal tendon. The
nasolacrimal duct extends from the inferior portion of the sac through
the nasolacrimal canal or bony conduit and travels 12 mm to the position
where it opens underneath the inferior turbinate in a space called
the meatus (see Fig. 4). The membranous conduit in most cases extends 5 mm farther downward and
usually is located in the vault portion underneath the inferior turbinate. However, again, there is some variability in the nasolacrimal
canal and duct, and it may open farther down on the lateral wall of the
nose in a slitlike manner (Fig. 5).

Fig. 5. Variations in position and shape of the opening of the end of the nasolacrimal
duct under the inferior turbinate. (Adapted from Shaffer JP: Types of ostia nasolacrimalia in man and their
genetic significance. Am J Anat 13:183, 1912.)

Structure The lining of the lacrimal canaliculi, the sac, and the nasolacrimal
duct is pseudostratified columnar epithelium similar to that found
in the upper respiratory system. The walls contain much elastic tissue. The
canaliculi, in particular, contain large amounts of elastic
tissue. In addition, the lacrimal sac and the nasolacrimal duct have
collagen, elastic fibers, and amounts of lymphoid tissue in the walls.2,3 The mucous membrane within the sac and nasolacrimal duct is arranged into
membranous folds that act as valves. The two most important folds, as
best as can be determined clinically, are the valve of Rosenmuller, where
the common canaliculus enters into the sac, and the valve of Hasner (plica
lacrimalis) at the end of the nasolacrimal duct under the
inferior turbinate. Other valvelike folds have been identified, as have
valvelike constrictions at the junction of the sac in the nasolacrimal
duct (valve of Krause, sinus of Arlt) and within the nasolacrimal
duct (spiral valve of Hyrtl and the valve of Taillefer; see Fig. 4).

ENCOMPASSING SOFT TISSUE

The muscles within the eyelid in front of the tarsus (pretarsal orbicularis), the
protractor muscles, are anchored at the lateral canthal tendon
and the lateral palpebral raphe. They travel horizontally across the
surface of the upper and lower tarsus, and as they reach the medial
canthal area they split into a superficial and deep portion or head. The
deep head of the pretarsal orbicularis muscle from the upper and lower
lid inserts on the lacrimal bone at the posterior lacrimal crest
behind the sac and in some cases has been referred to as Horner's muscle. An additional strand of orbicularis muscle from the preseptal area in
the lower lid inserts on the periosteum, which covers the lacrimal sac
and its fossa, which extends from the posterior to the anterior lacrimal
crest described by Jones.4 The superficial head of the pretarsal orbicularis and preseptal orbicularis
fibers insert in a dense conjoined medial canthal tendon anterior
to the fundus of the lacrimal sac (Fig. 6).

Fig. 6. Diagram of the tendon and insertion of the eyelid muscles in and around
the lacrimal sac and canaliculus. (Adapted from Jones LT: An anatomic approach to problems of the eyelids
and lacrimal apparatus. Arch Ophthalmol 66:137, 1961.)

Much has been written and hypothesized about the mechanism of lacrimal
elimination. The abundance of theories and conflicting information in
the literature often serves to dissuade practicing clinicians from investigating
this topic. A basic understanding of lacrimal physiology, however, is
a useful foundation for making treatment decisions about many
lacrimal disorders.

The tear film travels across the surface of the globe and eyelids, enters
the puncta/ampulla, passes through the canaliculi, and enters the lacrimal
sac/nasolacrimal duct/nasal passages. This schema is of course
oversimplified, because much of the tear film is likely “eliminated” by
direct evaporation or absorption at the level of the lacrimal
sac. The first key physiologic point to understand, however, is
that the lacrimal outflow system is based on an active, dynamic pumping
mechanism. It has long been noted that the blinking mechanism readily
drains tears even with the head held in an inverted position. When
the palpebral blink mechanism is impaired, however, epiphora is common, such
as in patients with facial paralysis.

Although multiple mechanisms may contribute to lacrimal outflow, present
evidence suggests that the most important factor is the active palpebral-canalicular
pump. This theory is based on the cumulative works of
Doane,5 Rosengren,6 Frieberg,7 Chavis and colleagues,8 and Maurice.9 the blink mechanism with high-speed photography. Carbon particles were
used to photograph the actual flow of the precorneal tear meniscus. The
important findings of this work are summarized as follows. With the
eyelids open before the start of a blink, the canaliculi are already
filled with tears. As the upper lid descends at the start of a blink, the
medial portion of the eyelids around the puncta elevates. The upper
and lower puncta come into forceful contact by the time the eyelids
are only halfway closed. This important event occludes the puncta such
that the remaining portion of the blink acts to compress the canaliculi
and lacrimal sac, thus forcing the contained fluid into the nasolacrimal
ducts and nasal passages. The volume of fluid within the lacrimal
outflow system is at its minimum at the point of maximum lid closure
during a blink. As the eyelids begin to open, the muscular compressive
force terminates and the elastic walls of the canaliculi and lacrimal
sac attempt to restore their original shape. The puncta remain occluded
such that a partial vacuum forms within the membranous lacrimal conduit. As
the eyelid-opening phase of the blink continues, the two lacrimal
puncta pop open and expose the adjacent lacrimal lake to this partial
vacuum. Tears rapidly flow into the canaliculi during the 1- to 3-second
interval immediately after the blink. Once again, the canaliculi
fill with fluid so that the pumping action of the next blink can continue
the lacrimal elimination cycle.

In addition to the important role of the active palpebral-canalicular pump, other
factors contributing to lacrimal elimination may include physical
forces such as gravity and capillary attraction of the tears, reservoir
drainage into the lacrimal sac (so-called Krehbiel flow), microcilliation
in the nasolacrimal duct, and finally evaporation of tears
from the ocular surface and absorption of tears by the lacrimal sac
mucosa.

The “lacrimal pump” theory is widely noted in the ophthalmic
literature and is based on classic anatomic studies by Jones,10 describing tendinous and muscular insertions exerting their action on
and around the lacrimal sac. The Jones theory holds that with closure
of the eyelid margin, the eyelid fissure moves nasally and forces tears
toward the area of the puncta and interface between the lids, conjunctiva, and
caruncle in the area of the lacrimal lake. With relaxation
of the eyelids on opening, the canaliculi and ampulla, which have been
compressed by the pretarsal deep and superficial muscles because of their
elasticity, create a negative pressure in the ampulla-canalicular
system, causing tears to be sucked into the puncta. When the eyelids
are closed again, the tears, which previously entered the ampulla-canalicular
system when the eyelids were opened, are squeezed into the lacrimal
sac. It is also theorized that the muscular pull of the preseptal
orbicularis muscles on the lacrimal sac creates a negative pressure
within the sac. With the eyelids open, the sac is normally collapsed. The
valves within the sac and nasolacrimal duct prevent retrograde passage
of tear flow in normal situations. This proposed lacrimal sac pumping
mechanism is based on anatomic studies and likely does not have a
large role in normal lacrimal elimination, because the system functions
quite well with the lacrimal sac slit completely open, as is the case
after dacryocystorhinostomy (DCR).

Traditional teachings have previously held that the lower canalicular drainage
system was far more important than the upper system. This old
wives' tale is completely incorrect. Studies by White and colleagues11 and Daubert and associates12 have demonstrated equal tear flow between the upper and lower canalicular
systems using radioactive dacryoscintigraphy flow studies. Linberg
and Moore13 evaluated the clinical symptoms associated with alternate monocanalicular
occlusion of the upper and lower puncta. They found that approximately 50% of
patients experience mild intermittent symptoms of epiphora
associated with experimental monocanalicular obstruction. The symptoms
were identical whether patients' upper canalicular system or lower canalicular
system was occluded. Meyer and associates14 studied fluorescein dye disappearance in 20 subjects and found that 90% of
patients showed minimal or no impairment with monocanalicular (either
upper or lower) obstruction.

A number of important clinical principles can be derived from the physiologic
information just provided. Present evidence supports the crucial
role of the palpebral-canalicular pump mechanism in lacrimal elimination. All
efforts should be made to preserve the lacrimal canaliculi. Repeated
instrumentation of the lacrimal system or nasolacrimal duct probings
are unlikely to help the underlying pathology and may in and of
themselves injure the canaliculi and thus permanently impair lacrimal
elimination. Very little can be done to restore scarred fibrosed canaliculi. Frieberg
has used a manometer to measure a pressure gradient
within the canaliculi and lacrimal sac.7 This pressure gradient cannot be produced if the canaliculus is slit open. This
information should caution clinicians against performing overly
aggressive procedures on the lacrimal outflow system, such as aggressive “three-snip” punctoplasties or aggressive surgical
treatment of canaliculitis. Experimental and clinical studies show that
tear elimination is equivalent through the upper and lower canalicular
systems.11–14 Surgeons should thus give equal consideration to a patient with lacerations
of either the upper or lower canaliculus. Traditional teachings
that upper eyelid canalicular lacerations are unimportant are simply not
true.

The anlage of the membranous lacrimal conduit is an ectodermal thickening
of a groove between the lateral, nasal, and maxillary process in the 12-mm-stage
embryo. After this stage, the anlage detaches and becomes
buried in the mesoderm. Solid cords of epithelial cells form the anlage
of the canalicular system in the eyelids, with a projection downward
that will form the nasolacrimal sac and the nasolacrimal duct at the 16-mm
stage. Canalization of these epithelial cords starts at the 50-mm
stage, or 4 months of gestation, beginning as scattered patches throughout
the system and creating a lumen through the system. This lumen
finally breaks through its latest stage in the nasolacrimal duct to
form a continuous opening just before birth. The lower end of the lacrimal
duct is the last to canalize, and in more than half of infants the
last portion of this nasolacrimal stem may not completely finalize its
patency at birth.15,16 During embryonic development, migrations of epithelial cords can cause
various anomalies within the lacrimal system.

Dacryostenosis is a common condition in which the extreme end of the nasolacrimal
duct underneath the inferior turbinate fails to complete its
canalization in the newborn period; it produces clinical symptoms in 2% to 4% of
newborns. In most instances, the obstruction is a small membrane
at the end of the nasolacrimal duct that persists because of failure
of complete canalization of the nasolacrimal duct. Other rarer
types of congenital occlusion of the nasolacrimal duct and canal may occur
if the epithelial cords have migrated within the mesoderm and do
not open immediately under the inferior turbinate. Blind pouches can occur
within the turbinate itself. A bony obstruction is often found under
the inferior turbinate, and in some cases the epithelial cord migrates
laterally so that the nasolacrimal canal ends in a blind pouch in
the lateral wall of the nose.17,18 There are normal variations in the position of the opening of the nasolacrimal
duct under the inferior turbinate. The nasal ostium of the duct, at
the highest portion of the inferior meatus within the vault beneath
the inferior turbinate, is usually wide open. It may be puckered, slitlike, or
grooved down the lateral wall of the nose or have a puncturelike
appearance in the vault of the turbinate (see Fig. 5).

ABSENCE OF VALVES

The fold normally present at the end of the nasolacrimal duct or valve
of Hasner may be absent, in which case pneumatoceles of the sac may occur
and nose blowing may cause retrograde passage of air. If the valve
of Rosenmuller is also absent, it is possible to blow air from the nose
into the eye, and nosebleeds may produce bloody tears.19

ANOMALIES OF THE SAC

Although diverticuli of the lacrimal sac may occur, a congenital fistula
of the lacrimal sac, which has been termed lacrimal anlage duct by Jones, is more common (Fig. 7).19 This anomaly has been described by others and in some cases is found to
be autosomal dominant and may coexist with thalassemia. It undoubtedly
is the result of canalization of a strand of epithelial cords that
extends from the sac to the skin surface. The fistulas often have to be
completely excised to prevent drainage of tears externally on the skin.

Congenital atresia, supernumerary or double puncta, and congenital slits
of the puncta all may occur from aberrations in the location of the
epithelial cord and its opening to the surface epithelium. Lateral displacement
of the puncta may occur in some congenital syndromes such as
blepharophimosis.

ANOMALIES OF THE CANALICULI

Atresia or failure of canalization of the lacrimal canaliculi may occur
in conjunction with punctal atresia. In many cases, particularly in patients
with mesodermal dysplasia, the lacrimal canaliculi and puncta
may be absent and a normal tear sac and nasolacrimal duct may be present
but not connected to the eyelid surface.

Neonates have tear secretion at birth, and 96% to 98% have a totally patent
and functional lacrimal drainage system.20 The 2% to 4% who do not have a lacrimal drainage system intact have a
thin residual membrane at the distal end of the nasolacrimal duct. This
membrane spontaneously dissolves in 80% to 90% of patients within the
first few months of life.21 Clinical manifestations of congenital nasolacrimal duct obstruction are
the following.

AMNIOTOCELE

This occurs in neonates as a distention in the lacrimal sac. Amniotic fluid
enters the sac, is retained by a nonpatent nasolacrimal duct, and
is trapped in the sac by the valve at the common canaliculus, the valve
of Rosenmuller. Probing the nasolacrimal duct as an office procedure
is usually curative.

DACRYOCYSTITIS (ACUTE MUCOCELE OR PYOCELE)

This condition also exhibits acute distention and inflammation in the lacrimal
sac region and may occur in the neonatal period. Probing is necessary
in newborns with acute dacryocystitis to establish drainage as
soon as possible. This procedure is performed with topical local anesthesia
only.

TEARING AND MATTERING

Newborns who have congenital dacryostenosis may not develop acute dacryocystitis
with a mucocele or pyocele of the sac in the early neonatal
period but may simply have tearing with a chronic mucopurulent discharge, which
usually becomes manifest at 2 weeks of age. Topical antibiotics
should be administered, and the parents must be instructed in the
proper technique of lacrimal sac compression and massage. More than 90% of
these cases clear and become asymptomatic with conservative management.22,23 Under normal circumstances, these children with mild to moderate symptoms
of epiphora and lid crusting can be monitored for the first year of
life without serious consequence or sequela (Fig. 8). There is rarely any imperative reason to make probing mandatory at an
early age (e.g., before 6 months of age). A number of studies have confirmed
that probing or silicone tube intubation in children after 12 months
of age still has a very high success rate. These techniques are
discussed later in the treatment section in this chapter.

Fig. 8. This 15-month-old child had congenital left nasolacrimal duct obstruction. Chronic
mattering of the left eyelashes and excess tearing are evident
in the left eye.

The normal position of the punctum is pointing inward toward the lacrimal
lake. It cannot be seen by an observer looking directly toward the
eyelid. The punctum can be displaced in a congenital anomaly with eyelid
syndromes such as blepharophimosis or congenital ectropion. Malposition
more commonly is an acquired anomaly in older individuals with eyelid
laxity and senile ectropion (Fig. 9). It also may occur after injury or burns with skin shrinkage, which results
in turning the punctum outward.

Isolated stenosis of the punctum with an intact and patent canalicular
system distally may occur congenitally or as a result of cicatrizing inflammations, trauma, and
senile atrophy associated with long-term drying
in patients with ectropion.

TUMORS

Basal cell carcinomas occur most frequently in the inner canthal area and
often involve the punctum, as may benign growths in this area.

Obstruction or atresia of the canalicular system may follow any of the
conditions discussed next.

Cicatrizing Conjunctivitis

Obstruction or atresia of the canaliculi may follow infections such as
herpes simplex, herpes zoster, vaccinia, trachoma, infectious mononucleosis,24–26 or other inflammations such as the Stevens-Johnson syndrome or ocular
pemphigoid.

Trauma

Chemical or thermal burns, dog bites, and other lacerations may also cause
obstruction or atresia of the canaliculi. At one time or another, every
ophthalmologist is called on to repair a canalicular laceration. Acute
lacerations of the canaliculi may occur after sharp penetrating
wounds or as a result of shearing or ripping wounds of the eyelid caused
by hooklike objects or teeth. The location of the lid laceration medial
to the lacrimal punctum heightens the examiner's suspicion
of the possibility of a canalicular laceration. If a patient is cooperative, the
canaliculus can be gently probed with a lubricated 00 Bowman
probe. Visualizing the shiny metal probe within the wound confirms the
presence of a canalicular laceration. In children and some adults, the
diagnosis of a canalicular laceration can be established only in the
operating room or during examination under anesthesia. As with any
adnexal injury, the ophthalmologist must perform a complete examination, including
dilated retinal examination, to rule out serious ocular or
intraocular injury.

Irradiation

Occlusion of the canaliculi and puncta occurs after irradiation for basal
cell carcinoma almost 100% of the time, although intubation with silicone
tubing may prevent this problem in some cases.27

Tumors

Skin cancer may involve the canalicular system, but intrinsic canalicular
tumors such as papillomas may occur, producing occlusion and secondary
inflammation.28

Use of Eye Drops

Echothiophate (Phospholine) iodide has been incriminated as a cause of
canalicular stenosis as well as ocular pemphigoid syndrome, and idoxuridine
toxicity may cause temporary occlusion of the punctum and canaliculus.29

Repeated Probing

One of the most common causes of stenosis of the lacrimal canalicular system
is repeated and traumatic probing of the canalicular system for
whatever reason.

Canaliculitis

Inflammation of the canalicular system can occur secondary to dacryocystitis, but
isolated bacterial infections of the canaliculus are rare. Perhaps
the most common infections are caused by Streptomyces, Actinomyces israelii, and Arachnia propionica (previously mislabeled as Streptothrix). Fungal infections with organisms such as Candida albicans, Aspergillus niger, and Nocardia have been reported. However, actinomycotic infection is by far the most
common.30 In the clinical presentation, the lower canaliculus is usually involved
and the patient reports epiphora. Swelling and inflammation of the lid
medially are noted (Fig. 10). The punctum is swollen and red, sometimes described as pouting, and
a mucoid and mucopurulent discharge is present. Irrigation may or may
not be possible through the canaliculus, and a small probe may encounter
gritty resistance. Diagnosis is made on expressing yellow-tinged concretions
from the canaliculus. On cytologic examination, they show gram-positive
branching filaments.

Fig. 10. Left upper lid canaliculitis with diverticuli formation of the canaliculus.

Allergy

Wojno31 has demonstrated intermittent allergic obstruction at the level of the
canaliculus or lacrimal sac. This phenomenon is associated with allergic
conjunctivitis and is noted in patients who chronically rub their
eyes.

Infections of the lacrimal sac are clinically manifested as either dacryocystitis, marked
by a tender and swollen lacrimal sac, rather severe
pain, redness, and tearing; or chronic dacryocystitis, characterized
by a smoldering infection within the lacrimal sac without distention of
the sac but producing tearing and, in many cases, a chronic unilateral
conjunctivitis (Fig. 11). Both conditions have as their underlying cause an obstruction to the
normal tear passage within the nasolacrimal duct and sac, causing stasis
and stagnation of tears and mucus and subsequent infection. The most
common organisms in the ensuing infections are pneumococci. Other organisms
include streptococci, diphtheroids, Klebsiella pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and mixed organisms. Actinomyces and fungi, such as Candida, are not infrequent, and granules and casts of the nasolacrimal duct and
sac may be present in these cases.32 Sarcoidosis producing a chronic recurrent dacryocystitis has been reported
in conjunction with systemic sarcoid.33,34

Fig. 11. Wegener's granulomatosis in a 71-year-old man. Acute dacryocystitis
with lacrimal sac rupture is present in his left eye. Chronic conjunctivitis
due to right nasolacrimal duct obstruction with chronic low-grade
infection is noted in his right eye.

LACRIMAL STONES OR CASTS

Casts or plugs may form within the lacrimal sac or nasolacrimal duct from
fungus infections, organized blood clots, or inspissated mucous plugs. The
most common organisms causing these seem to be A. israelii and Candida species. The clinical signs are intermittent epiphora and lacrimal obstruction, lacrimal
conjunctivitis, recurrent or intermittent dacryocystitis, and
variable localized tenderness. The underlying causes of the
formation of stones are unclear. However, they occur more frequently
in younger (under age 50) individuals and in heavy smokers.32 In many cases, it is possible to express, irrigate, and probe casts through
the nasolacrimal duct, but DCR may be needed. A syndrome of acute
noninfectious dacryocystic retention may occur when a cast, which may
be mobile, plugs the nasolacrimal duct.35 Fluid buildup in the lacrimal sac causes closure of the valve of Rosenmuller
at the common canaliculus, and the sac becomes acutely swollen
and tender. This can be treated by percutaneous aspiration of the sac, followed
by probing and irrigation. Casts may occur from chronic use
of epinephrine drops.36

DACRYOCYSTITIS

The differential diagnosis of dacryocystitis includes a number of different
clinical entities. The presentation of a mass in the lacrimal sac
may be caused by a noninfectious amniotocele in a neonate or acute dacryocystic
retention in an adult. Lacrimal sac neoplasms, unless attended
by infection, are generally not tender and have a slower onset. In
neoplastic disease, the mass in many cases extends above the level of
the medial canthal tendon, which does not occur in dacryocystitis because
of the compression of the fundus of the sac by the medial canthal
tendon. Neoplasms that arise extrinsic to the lacrimal sac area include
nasopharyngeal carcinomas, orbital rhabdomyosarcomas, and tumors of
the antrum. A congenital midline meningoencephalocele may present as
a mass in the lacrimal sac area and cause a secondary dacryocystitis. This
anomaly may or may not communicate with the intracranial cavity. Dermoid
cysts occur quite commonly nasally, although they are more often
located in the supra-nasal quadrant and most usually are located at
the lateral brow. Ethmoidal and frontoethmoidal mucoceles can occur and
produce a firm masslike swell-ing at the inner canthal area and also
a secondarydacryocystitis. Skin cysts and inclusion cysts maysimulate
a mass in the lacrimal sac area. A chronicunilateral conjunctivitis
with tearing and purulentdischarge from the lower canaliculus that occurs
with dacryocystitis also can be encountered in isolated canaliculitis.

TUMORS

Clinical signs of a lacrimal sac tumor are tearing, painless irreducible
swelling in the lacrimal sac area, and secondary dacryocystitis. Bleeding
on probing of the lacrimal system is not an infrequent finding in
sac tumors. It may be possible to irrigate through the lacrimal sac
containing a tumor before the tumor completely occludes the lacrimal drainage
system. Extension of tumors outside the sac area may cause intranasal
symptoms, and radiographic changes are noted with erosion in the
bone. Injection contrast radiography (dacryocystography) of the lacrimal
sac may also demonstrate a nonfilling mass but may add little to
the diagnosis, which may already be suspected. Historically, series of
primary lacrimal tumors have been reviewed by Ashton and colleagues,37 Jones,38 and Radnot and Gall.39 Additional cases have been reported by Ryan and Font,40 Schenck and associates,41 and Stokes and Flanagan.42 In one series, about a third of the “tumors” were pseudotumors
and were described as nonspecific granulomas, rhinoscleroma, lymphomatous
lesions, sarcoid, syphilis, and fungi.39 In most series of true neoplasms of the lacrimal sac, 50% to 60% arise
from the epithelial lining of the sac and are of the papillary carcinoma
group, with histologic pictures identical with solid cylindric cell
tumors arising from the respiratory epithelium.40

The well-differentiated papilloma group should be treated by local excision
and have a favorable prognosis, although the rate of recurrence is
high. It has been recommended that all of the membranous lacrimal drainage
apparatus, including the canaliculi and nasolacrimal duct, should
be excised. The papillomas are classified into three histologic types: squamous
cell, transitional cell, and mixed cell. They are all resistant
to radiation therapy. The carcinomas are histologically squamous
and transitional cell carcinomas, and they also may arise from the degeneration
of a pre-existing papilloma. In Ryan and Font's series, the
survival rate of these patients after a wide local excision with
frozen-section control was “reasonably good.”40

The wall of the lacrimal sac contains lymphoid tissue, and lymphomas are
probably the second most common intrinsic lacrimal sac tumor. They are
similar to lymphomas occurring in the orbit in that they may be forerunners
of lymphoid disease elsewhere in the body or the head and neck. The
ultimate prognosis may be improved by noting the presence or absence
of follicles, the anaplasia of the cells, and cell surface immunology.43 After biopsy and systemic evaluation, radiotherapy is indicated. Intubation
of the lacrimal passages with silicone tubing before irradiation
is indicated, and normal lacrimal drainage function for the patient after
treatment may be retained.

Other primary lacrimal sac tumors that have been reported are malignant
melanoma,44 oncocytic adenocarcinoma,45 neurilemmoma,46 adenocanthoma,47 hemangiopericytoma,48 and fibrous histiocytoma.49

The differential diagnosis should include invasive pharyngeal or sinus
carcinoma and mucoceles of the ethmoidal sinus, which can be demonstrated
on computed tomography scans. Rarely, orbital rhabdomyosarcomas present
in this manner, and other mass lesions, previously mentioned, should
be considered.

Primary acquired nasolacrimal duct obstruction (PANDO) is the most common
clinical syndrome of acquired nasolacrimal duct obstruction in adults. Patients
may present with symptoms of chronic epiphora, conjunctivitis, and
low-grade infections or with acute dacryocystitis. This clinical
syndrome is most common in elderly white women.

Clinical pathologic studies by Linberg and McCormick50 examined the histopathology of the entire membranous nasolacrimal duct
in patients with the clinical syndrome of PANDO. These studies have revealed
inflammation, vascular congestion, and edema of the nasolacrimal
duct in the early phases and, ultimately, fibrosis with complete occlusion
of the nasolacrimal duct's lumen in the late phases.

The specific trigger of this sequence of events is not known. Nonetheless, it
is reasonable to postulate that inflammation with partial ductal
obstruction leads to accumulation of cellular debris, which aggravates
the ongoing inflammation and creates a vicious cycle that leads to
permanent cicatrization of the nasolacrimal duct lumen.

Linberg's studies have demonstrated that in patients with symptoms
of relatively short duration (less than 1 year), the inflammation and
edema “functionally” occlude the nasolacrimal duct. A potential
space does remain within the lumen, however. This pathologic finding
lends credence to the hope that PANDO may be reversible in patients
with symptoms of short duration. For this reason, as discussed later
in the treatment section, this subset of patients may be candidates
for either medical therapy with antiinflammatory drugs or nasolacrimal
duct intubation with silicone tubes to maintain patency of the duct
until the inflammation subsides or has been treated.

Patients with PANDO and chronic symptoms (greater than 2 to 3 years' duration) demonstrate
dense fibrous scar tissue and cicatrization of the
nasolacrimal duct as a sequela of chronic inflammation, edema, and stasis
of cellular debris. In these patients, the lumen of the nasolacrimal
duct is permanently obliterated by scar tissue. This histopathologic
finding correlates with the very poor success rate of nasolacrimal
duct probing or intubation with silicone lacrimal tubes in adult patients
with chronic PANDO symptoms. As discussed later, DCR remains the treatment
of choice for this group of patients.

Although most adult nasolacrimal duct obstructions represent the syndrome
of PANDO, noninflammatory infiltrative disorders can occlude the nasolacrimal
duct. Clinicians must maintain a high index of suspicion in
patients with known systemic disorders such as sarcoidosis, lymphoma, or
leukemia. In these situations, distal nasolacrimal sac or nasolacrimal
duct biopsy is an important part of the DCR surgery. Linberg and
McCormick recommend their nasolacrimal duct biopsy technique as a routine
part of all DCRs.50 In this manner, important infiltrative causes of nasolacrimal duct obstructions
would not be overlooked.

TRAUMA

Nasolacrimal duct obstructions may occur as a sequela of midfacial fractures
involving the bony nasolacrimal canal. Immediate disruption of the
nasolacrimal drainage system occurs in some patients. This is typical
of severe crushing nasal orbital fractures and the Lefort II and LeFort
III fractures, in which extensive damage is sustained by the entire
lacrimal drainage apparatus, including the canthal tendons. In other
patients, bony fractures initiate an inflammatory, cicatrizing process
that results in symptomatic nasolacrimal duct obstructions many years
after the original injury. Some investigators have advocated early
silicone tube intubation of the lacrimal outflow system in patients with
complex midfacial fractures.51 The efficacy of this treatment is not yet fully established.

A number of cases of dacryostenosis have been reported after cosmetic rhinoplasty. It
is believed that in most instances, the damage to the membranous
nasolacrimal duct occurs during the lateral osteotomy.52 Other sinus and nasal operations may also injure the nasolacrimal duct. This
is especially true of Caldwell-Luc procedures and nasoantral window
formation. Nasoantral windows are usually created in the most anterior-inferior
portion of the maxillary sinus. If they are placed too
high or too posterior, however, or if the nasolacrimal canal is in an
anomalous position, excision of a portion of the nasolacrimal duct may
occur. The Ogura procedure (orbital decompression) with excision of the
floor of the orbit and ethmoidal air cells through an antrostomy may
also be associated with postoperative epiphora. Again, the likely cause
may be the nasoantral window formation.53,54

Prior midfacial or nasal radiation therapy may result in nasolacrimal duct
obstructions. In prior generations, radiation treatment was common
for conditions such as facial acne and chronic sinusitis. As with some
traumas, this occlusive radiation fibrosis effect may be delayed for
many years.

INTRANASAL DISORDERS

The distal aspect of the nasolacrimal duct may be obstructed as a result
of intranasal pathology. Intranasal scarring with inferior turbinate
adhesions may occur as a sequela of trauma, radiation therapy, or surgical
procedures (e.g., nasoantral window formation). Allergic rhinitis
may be associated with nasal mucosal hypertrophy. In some individuals, an
abnormally wide nasal vestibule is associated with compensatory
hypertrophy of the inferior turbinate that occludes the valve of Hasner (open
nasal space syndrome with epiphora).55 Tumors are uncommon and can be benign, such as granulomas or nasal polyps, or
malignant, such as squamous cell carcinoma.

As indicated previously, the lacrimal outflow system may be anatomically
patent to irrigation yet be functionally inadequate in terms of normal
lacrimal elimination. Facial nerve paresis is among the most common
situations in which lacrimal pump failure is present despite patency
of the membranous lacrimal conduit. Any condition that impairs the normal
contractile and elastic properties of the palpebral-canalicular pump
mechanism can cause epiphora. These conditions include scleroderma, radiation
fibrosis of the eyelids, and cutaneous burns or trauma of the
periocular region. Chronic or recurrent canaliculitis may leave the
canaliculi anatomically patent yet functionally impaired.

The most common symptom of disorder in the function or anatomy of the lacrimal
drainage system is tearing. The blockage or malfunction may occur
at many places along the tear elimination route, and the appropriate
therapy, surgical and nonsurgical, may be necessary to correct it. Some
patients with tearing symptoms truly produce more tears than the
normal drainage system can handle, and some people may have conditions
that cause more of a sensation of tearing than actual overloading of
the drainage system. Table 1 shows a classification of the various physiologic and anatomic causes
of tearing.

The steps necessary in evaluating a patient with tearing are listed below
in the usual sequence. In many cases, not all the steps are needed
because the diagnosis may be apparent with some of the more simple tests
alone.

History

Slit-lamp examination (noting lid movement and position and integrity of
punctum)

Pressure over lacrimal sac

Irrigation of lower canaliculus

Intracanalicular probing (diagnostic)

Dye drainage tests (fluorescein test) for functional blocks

Schirmer's test

Intranasal examination

Conventional x-ray films and computed tomography

Dacryocystography

Dacryoscintigraphy

A patient presenting to an ophthalmologist with tearing should be evaluated
in a systematic manner, and the proper sequence should be observed
to promote efficient use of time and to avoid confusion.

HISTORY

In evaluating a patient with tearing symptoms, no diagnostic technique
is more valuable than taking a careful history. A unilateral watering
eye is more commonly a sign of an obstructive process, although bilateral
nasolacrimal duct obstructions can occur. Is there actual excess tearing
in which tears run down the patient's cheek(s) and require
frequent dabbing, or does the patient have diminished visual acuity and
simply refer to the sensation as “my eye is tearing”—a
common complaint of patients with macular degeneration.

The primary consideration for clinicians is to distinguish epiphora from
hyperlacrimation. Epiphora denotes symptoms of excess tearing due to
lacrimal outflow deficiency. Hyperlacrimation denotes that an excess
production of tears accounts for the patient's symptoms. Table 1 shows a classification scheme for tearing disorders, including the differential
diagnosis of epiphora and hyperlacrimation.

Patients with hyperlacrimation commonly have ocular discomfort. A chronic
gritty foreign body sensation associated with excess tearing is typical
of patients with keratitis sicca (“dry eye” syndrome). Patients
with entropion or trichiasis, blepharitis, corneal abrasions, chronic
conjunctivitis, or photophobia and iritis also frequently have
hyperlacrimation symptoms. In addition to the comfort of their eyes, patients
should be questioned about prior seventh nerve palsy or increased
tearing while eating.

Patients with epiphora commonly have “excess tears” as their
only symptom. The examiner should carefully question the patient about
intermittent redness of the eyes, mucous production or heavy lid crusting
in the morning, pain or swelling in the region of the lacrimal
sac, or prior episodes of acute dacryocystitis. These symptoms may indicate
chronic or intermittent dacryocystitis. Severe, intermittent symptoms
of tearing or dacryocystitis that are interrupted by completely
normal periods may suggest a “ball valve” disorder such as
dacryolithiasis. The clinician should question the patient with epiphora
to focus on the key anatomic areas of interest. A history of facial
nerve paresis, scleroderma, or lid scarring may indicate a dysfunctional
lacrimal pump mechanism. The chronic use of phospholine iodide, idoxuridine, or
prior severe conjunctivitis can point toward punctal stenosis
as the problem. A history of previous lacrimal therapy may be significant. Repeated
probing or instrumentation of the lacrimal canaliculi
can result in severe canalicular stenosis. Prior “overaggressive” punctoplasties may actually impair tear elimination. Patients
should be questioned about a history of chronic allergies or sinusitis, previous
nasal or sinus surgery, and prior midfacial fractures
or radiation therapy. Any of these would be pertinent in considering a
possible nasolacrimal duct obstruction.

The age of the patient (child, adult, elderly) and the duration of the
symptoms (acute, chronic) are relevant. These variables have an important
bearing on the likely cause of the problem and thus greatly influence
the treatment that is implemented. Childhood lacrimal obstructions
are usually due to an imperforate membrane at the distal nasolacrimal
duct. Adults, once hyperlacrimation has been ruled out, commonly have
the syndrome of PANDO. This type of adult lacrimal obstruction is potentially
reversible if the blockage is functional or if symptoms have
been of a relatively short duration (less than 6 months). Chronic epiphora
symptoms (greater than 12 months) are rarely treatable with any method
other than definitive DCR. Specific management of these epiphora
problems is expanded on in the treatment section.

EXTERNAL EXAMINATION

The puncta should be examined with the use of the slit lamp. They should
be positioned in the lacrimal lake and should not be visible without
mild eversion of the lid. The eyelid movement, with each blink, is normally
a nasalward compression in which the lids are completely in contact
with the globe and move toward the inner canthal area. There should
be no mechanical or contour obstruction of the margin impeding the
movement of the tear film across the lower lid into the lacrimal lake. The
punctal opening should be patent without stenosis or external occlusion. External
diseases of the eyelids that may be irritating, or keratitis
that may be producing a hypersecretion of tears, must be detected. The
flow of fluorescein into the punctum can be observed. Swelling
and redness of the punctum in the canaliculus may indicate canaliculitis.

PRESSURE OVER LACRIMAL SAC

A simple, quick confirmatory test for sac and nasolacrimal duct infection
and probable obstruction, particularly when a patient has a history
of dacryocystitis, is massaging of the tear sac. The sac may or may not
be distended; however, regurgitation of mucus or pus through the canaliculus
and puncta is indicative of dacryocystitis and obstruction, either
intermittent or permanent, in the nasolacrimal duct or sac.

IRRIGATION OF CANALICULUS

Syringing saline into the lower punctum demonstrates complete or severe
obstruction in the nasolacrimal duct or sac if saline regurgitates through
the upper punctum. This regurgitated substance may be clear or accompanied
by mucopurulent material and is diagnostic of obstruction in
the nasolacrimal duct or sac. Saline that irrigates into the nose with
syringing indicates only that there is not a complete obstruction in
the membranous conduit of the lacrimal system. It does not rule out
an incomplete block (partial block) or what has been termed a functional block, which may prevent tear passage into the nose under normal tear flow pressure. With
irrigation of the lower canaliculus, if the saline neither
goes into the nose nor regurgitates from the upper punctum and pressure
is encountered, the obstruction is in the canalicular system. The
proper irrigating technique with a 5-mL syringe and irrigating cannula
or a blunted 26-gauge needle is to flush the solution through the canalicular
system into the nose so that it may be recovered (i.e., the patient
leans forward over a small emesis basin). This is necessary so
that the fluid may be examined for casts.

PROBING

Probing is used only as a diagnostic measure in adults to determine the
location of a stricture in the canalicular system. No larger than a 00 probe
should be used. The residual length of patency in a canaliculus
can be determined in this manner, and thus the best possible corrective
procedure can be selected.

DYE (FLUORESCEIN) TESTS

Dye (fluorescein) tests are mainly useful in the differential diagnosis
of epiphora occurring in patients with incomplete or functional blocks
of the sac or nasolacrimal duct (i.e., patients with clinical tearing
and a narrowing in the membranous conduit but in whom saline can be
syringed into the nose with pressure applied on the syringe). Even though
there is some opening in the membranous conduit, the normal pressure
of tear flow under physiologic conditions is inadequate to eliminate
the tears, and in these patients the symptoms of tearing are usually
just as severe in most cases as in patients with complete obstruction.

To determine whether the tears are passing into the nose under normal physiologic
pumping conditions, the precorneal tear film is stained by
instilling 2% fluorescein solution. The inferior turbinate in the floor
of the nose laterally is then sprayed with decongestant and topical
anesthetic. A dry cotton roll fluff, about one third the diameter of a
cigarette, is wrapped around a nasal wire (or a straightened paper clip) and
placed under the anterior half of the inferior turbinate (cotton
applicator sticks are too large to find adequate placement under the
turbinate). Within 5 minutes, the cotton is removed and examined for
staining. If the cotton is stained with fluorescein, then the tear flow
through the lacrimal system is normal. If no dye is present on the
cotton at the end of this time, then a functional nasolacrimal block is
highly possible. This is the primary dye test as described by Jones
and Linn.56 (They originally called the test “negative” if no dye was
present, creating a source of much confusion because in medical thinking
the word negative generally means no pathology.) If dye can be obtained from under the turbinate
in the described manner in a patient with true tearing, then
the problem is hypersecretion and not deficient lacrimal drainage or elimination. In
a tearing patient in whom the dye does not flow through
under the turbinate, a second step is needed. The lower canaliculus is
then irrigated with saline, in a manner in which it can be recovered (i.e., having
the patient lean forward and expectorate into an emesis
basin) and examined for staining. If the fluid recovered in this manner
does have fluorescein staining, this finding indicates that the dye
enters the sac normally but does not pass through the duct into the nose, thus
confirming the diagnosis of incomplete or functional block of
the nasolacrimal duct. DCR is then indicated. This second step is the
secondary dye test of Jones. If the irrigated saline is not stained
with fluorescein as it is syringed through, this finding indicates that
the dye is not even entering the canaliculus and the sac, and previous
examinations and tests must be repeated for obstructions that have
been missed higher up in the lacrimal drainage system.

Other tests for functional or incomplete blocks of the nasolacrimal duct
are the dye disappearance tests57 and the taste test with saccharin.58 Examination of intranasal cotton to determine the presence of fluorescein
was also believed to be enhanced by the use of ultraviolet light. The
disappearance of dye from the conjunctival sac is not specific for
nasolacrimal duct obstruction and may be influenced by other factors. A
sweet or bitter fluid, if instilled in the conjunctival cul-de-sac, may
never reach the taste buds for reasons other than nasolacrimal duct
obstruction, and any subjective tests are objectionable. The use of
ultraviolet light to detect the faintest trace of fluorescein may show
some dye getting through the drainage system despite the clinical situation
of a functional block.

The dye tests as proposed by Jones and others56,59 are the most valuable tools to diagnose functional nasolacrimal blocks. However, they
are certainly not quantitative in that the time sequence
of the appearance of the dye and the absolute amount of the dye that
is actually passed are not measured. It is obvious that all functional
blocks are not of the same severity, and more sophisticated tests are
needed to quantitate the severity of functional blocks.

Dye Disappearance Test

The fluorescein dye disappearance test is a safe, simple, physiologic indicator
of a patient's lacrimal outflow system.60 This objective test can be very helpful in diagnosing (or verifying) lacrimal
drainage insufficiency.

This test relies on one drop of 2% sodium fluorescein instilled in the
lower conjunctival cul-de-sac. It is most helpful when both sides are
tested simultaneously. In this manner, dye disappearance is evaluated
over a 5-minute period. Clinically, the epibulbar surface appears intensely
yellow as the fluorescein drop is instilled. Patients commonly report
that “things appear yellow.” The examiner must take
note of any asymmetric overflow of fluorescein over the lid margin. This
can give false and misleading results. Patients must be kept from dabbing
or wiping their eyes.

The dye disappearance test is graded at 5 minutes on a scale from 0 to 4+ ; 0 represents
no dye remaining and 4+ indicates that virtually
all of the dye remains. Normal eyes exhibit a faint yellow fluorescein
color (e.g., ½ to 1+ ) at the end of 5 minutes. Attempting
to grade or quantitate the remaining fluorescein dye in an eye
is a highly subjective maneuver. In evaluating unilateral tearing symptoms, it
is often more helpful simply to compare the dye disappearance
results of the patient's two eyes.

Elderly patients with intermittent epiphora symptoms may not always have
a grossly exuberant precorneal tear film. The dye disappearance test
is a simple, objective means of assessing lacrimal outflow function in
these patients. The dye disappearance test is also quite useful in ascertaining
the tear outflow function in patients who have undergone DCR.

SCHIRMER'S TEST

Patients who have normal lacrimal drainage as diagnosed by the tests described
may still have tearing symptoms due to “pseudoepiphora.” This
condition is characterized by an actual deficiency of basic
tear secretion with overcompensation of tear production from the main
lacrimal gland, causing a watery eye.

Rough quantitation of tear production is aided by the use of Schirmer's
test strips (Whatman number 41 filter paper, a 35-mm-long and 5-mm-wide
strip). The filter paper strip is folded at the notched indentation, and
the short end is draped over the lower lid margin. The first
Schirmer's test is performed without anesthesia during a 5-minute
period. Filter paper wetting between 10 and 30 mm is considered normal. This
test measures basic secretion and reflex tearing. The second
Schirmer's test measures wetting caused by irritative nasal stimulation (e.g., cotton-tipped applicator) and is a test for possible fatigue
block in the reflex arc between trigeminal sensory nerve fibers
and the facial nerve.

The traditional test for dry eye syndrome is the Schirmer's test with
anesthesia, or so-called basic secretory test (BST). In this test, topical
anesthetic drops are instilled in the eye, and the excess is
blotted from the inferior conjunctival cul-de-sac. The Schirmer's
test strips are then draped over the lid margin for 5 minutes. Although
this test is still widely used, it is highly unlikely that it accurately
measures basal tear secretion. There is considerable doubt, in fact, about
whether a steady basal rate of tear production even exists.61,62 In all likelihood, the BST measures both basic secretion and some reflex
tearing. To label all patients with wetting of less than 10 mm as having
dry eye syndrome is an oversimplification. The BST is a roughly
quantitative test only. We do attach significance to severely limited
amounts of filter paper wetting (0 to 2 mm of wetting), and these patients
may have symptoms of pseudoepiphora.

INTRANASAL EXAMINATION

An intranasal examination is necessary in patients in whom an obstruction
in the sac or nasolacrimal duct is demonstrated. After the intranasal
cavity is sprayed with anesthetic and decongestant, a nasal speculum
is introduced with the blades oriented vertically to avoid pressing
on the intranasal septum when the blades are separated. With a headlight (an
indirect ophthalmoscope may be used), the intranasal cavity is
examined, To see the middle turbinate and the area in front of the turbinate, the
examiner must look upward into the nose with the patient's
head tilted backward and note any septal deviation, turbinate disease, or
polyposis that may produce technical problems with DCR or Jones' tube
procedure. To examine the inferior turbinate area, the inferolateral
corner of the nasal cavity, the examiner must look straight into
the nose and slightly downward to be able to see the tip of the inferior
turbinate and examine it for evidence of disease or an obstructive
process that could be the cause of the tear drainage. An intranasal
neoplastic process must always be kept in mind.

CONVENTIONAL X-RAY FILMS

Plain films or computed tomography scans are helpful when paranasal sinus
disease or tumors are suspected. Ethmoidal sinus enlargement such as
ethmoidal mucocele or anterior encroachment of the ethmoidal mucocele
area may be detected, as well as any erosion that may be caused by a
neoplastic process.

DACRYOCYSTOGRAPHY (INJECTION CONTRAST RADIOGRAPHY)

Dacryocystography, a technique of anatomically displaying the lacrimal
sac and ducts by radiopaque dye, was popularized by Milder and Demorest.63 Radiopaque dye is forcibly injected into the lower canaliculus with a
syringe, using a lacrimal cannula or a polyethylene tube. Radiographs
in the Caldwell and lateral views are taken. Preliminary syringing of
the lacrimal sac with saline before injection of the dye should be performed
to cleanse the sac and make room for the dye. Dye should be wiped
from the lids before x-ray films are taken to avoid obscuring details, and
oblique views instead of lateral views should be obtained radiologically
if both sacs are to be x-rayed simultaneously. Dacryocystography
may be helpful in showing the size of the sac, the relationship
of the ethmoidal air cells to the lacrimal sac, filling defects in the
sac such as lacrimal casts or lacrimal sac tumors, diverticula and fistulas
of the sac, and possibly the exact level of the stricture within
the lacrimal sac or nasolacrimal duct (Fig. 12). Dacryocystography is not a test of function, because the dye is forcibly
injected, and it is of no value in diagnosing a functional block. It
does not demonstrate the canaliculi and, in fact, in most cases bypasses
them completely. Most surgeons believe that conventional dacryocystography
does not alter the clinical approach to patients or affect
the therapeutic decisions that can be made at the time of surgery, because
a high index of suspicion for unusual conditions may already be
present from other clinical signs. Dacryocystography can, however, be
a useful adjunct for confirmation of a problem.

Fig. 12. A. Normal dacryocystogram (Waters' view roentgenogram). The contrast dye
fills the normal left lacrimal sac and nasolacrimal duct. Contrast dye
collects along the floor of the nose as it exits from the distal nasolacrimal
duct. B. Abnormal dacryocystogram. Contrast dye fills a grossly enlarged lacrimal
sac with ectasias in a patient with a functional nasolacrimal duct
obstruction.

More sophisticated techniques using x-ray cinematography may be helpful.64 A more precise instillation of the dye into the lacrimal system with x-ray
subtraction techniques has been introduced, entitled intubation microdacryocystography. It has been suggested that more subtle abnormalities can be seen, and
indeed, those that may produce the functional block can also be demonstrated.65

DACRYOSCINTIGRAPHY

In 1972, Rossomondo and colleagues66 introduced a test in which aqueous radioactive tracer (sodium pertechnetate) is
introduced into the tear film by a dropper. By scanning the
lacrimal area with a gamma camera with a 3-mm pinhole collimator, an examiner
can follow the progress of the radioactive tracer in the tears
into the canaliculi, the lacrimal sac, the nasolacrimal duct, and the
nose. Because the material is not injected, it identifies the tear progress
and elimination under physiologic or normal circumstances. Hurwitz
and associates65 introduced quantitative lacrimal scintigraphy using a gamma camera interfaced
with a computer in which the transit time of the tracer through
the canaliculi, the sac, and the nasolacrimal duct in a tearing patient
is compared with that of a normal individual. Subsequent studies have
shown it to be a very sensitive test of canalicular function and of
the adequacy of the lacrimal canaliculi pumping mechanism, but it is
not as sensitive a test for the elimination of tears from the sac and
nasolacrimal duct.67 These researchers suggest that the elimination of tears from the sac and
the nasolacrimal duct is more passive, dependent on gravity, influenced
by head position, and influenced by the volume of tears that has
accumulated in the sac. Further standardization of testing conditions, however, may
make this quantitative dacryoscintigraphy meaningful in
evaluating a tearing patient's entire lacrimal drainage pathway. At
present, dacryoscintigraphy appears to be a useful adjunct to conventional
tests but may increase in practicality in the future.

SUMMARY OF DIAGNOSTIC TECHNIQUES

This section has presented many of the available diagnostic techniques. In
most patients, a few of the simple tests alone will solve the problem.

A clinician's first priority should be to separate hyperlacrimation
from true epiphora. History and slit-lamp examination commonly reveal
signs and symptoms of ocular irritation with associated reflex hyperlacrimation. The
fluorescein dye disappearance test is a simple, objective
means of demonstrating a lacrimal outflow deficiency to help confirm
the diagnosis of epiphora. The next maneuver is to irrigate fluid
through the canaliculus. If 100% of the fluid refluxes from the opposing
punctum, the diagnosis is a nasolacrimal duct obstruction and the workup
is almost complete. If fluid irrigates into the pharynx (nasal passages), an
examiner must consider more subtle means of testing for a
functional nasolacrimal duct obstruction or other causes of epiphora (see Table 1).

Lid laxity and orbicularis strength must be carefully re-examined. Correct
punctal position is often best verified by slit-lamp examination. Patients
should be closely examined for subtle evidence of facial nerve
paresis. In patients with horizontal laxity, it may be helpful to “tighten” their
lower lids with tape. This office maneuver can
help identify patients in whom surgical horizontal lower lid tightening
will alleviate epiphora. The Jones I and II dye tests can further
define a patient's lacrimal outflow system capability. These dye
studies should be performed under physiologic conditions. They should
generally not be performed on the same day after vigorous irrigation
or extensive manipulation of the lacrimal drainage system. The Jones I
and II dye tests are useful in verifying a lacrimal outflow deficiency
and localize the disorder to the upper system (lids, puncta, ampulla, canaliculi, or
common canaliculus) or the lower system (lacrimal sac, nasolacrimal
duct, or intranasal passages).

In select patients, radiographic studies may be helpful in confirming the
clinical evaluation. The 30-minute dacryocystogram dye retention study
is useful in confirming a nasolacrimal duct obstruction. In this test, water-soluble
contrast dye is irrigated through the lacrimal outflow
system. A simple Waters' view roentgenogram is taken 30 minutes later. The
presence of a significant amount of retained contrast dye in
the lacrimal sac or nasolacrimal duct indicates a functional obstruction
of the nasolacrimal duct. In other patients, radionuclide dacryoscintigraphy
may yield physiologic information about the canalicular pump
and the entire lacrimal outflow system.

As has been emphasized, a proper diagnosis is the prerequisite for implementing
the correct therapy.

EYELID/PERIOCULAR SURGERY

In most patients with lower eyelid punctal malposition, the cause is excessive
horizontal lower eyelid laxity. These malpositions are corrected
with a simple lower eyelid horizontal tightening procedure performed
at the outer canthus.68,69 These tightening procedures restore adequate horizontal tension to the
lower eyelid and often correct any punctal ectropion. The tightening
effect of surgery can be simulated with a piece of tape used to tighten
the lids. This maneuver is helpful in predicting which patients may
be helped by definitive surgery. In some patients, punctal ectropion can
be corrected by medial transconjunctival tightening and rotation procedures.70,71 These medial rotational procedures rely on the excision of a diamond-shaped
ellipse of conjunctiva and lower eyelid retractors from the retropunctal
region. Suture closure of the cut edges of conjunctiva and lower
eyelid retractors can be brought full thickness through the lid to
enhance the rotational effect, as advocated by Tse.71 These medial spindle procedures for correction of punctal ectropion can
be combined with lateral horizontal tightening procedures.

Conjunctivochalasis is the term used to describe redundant epibulbar conjunctiva that is interposed
between the globe and lower eyelid and protrudes over the lower
lid margin.72 This redundant fold of conjunctiva interferes with the normal tear meniscus
and can be seen to be draped over the lower eyelid punctum in affected
patients. The treatment is surgical excision of a strip of redundant
conjunctiva. Serrano and Mora have recommended that an inferior
limbal peritomy be used to excise the redundant conjunctiva.73 This incision heals quite well and avoids scarring or retraction of the
inferior conjunctival fornix. Other investigators have reported success
with excision of a redundant crescent of epibulbar conjunctiva located 3 to 4 mm
below the inferior corneal limbus.74,75 With either method, the surgeon must avoid overzealous excision of conjunctiva.

PUNCTAL SURGERY

Punctal stenosis is an underdiagnosed and relatively simple-to-treat cause
of epiphora. The one-snip punctoplasty is successful in most cases.76 The follow-up treatment of patients undergoing punctoplasty is as important
as the actual procedure itself.

A one-snip punctoplasty may be performed with topical anesthesia, although
we prefer a small local infiltration with lidocaine 2%. If the punctum
is completely stenosed, a sharp probe may be necessary to initiate
a small opening. This small punctal opening should then be gently dilated. A
one-snip punctoplasty is performed with sharp Westcott's
scissors. The Westcott's scissors are held perpendicular to the
lid margin, and one blade of the scissors is introduced into the dilated
punctum and ampulla. A vertically oriented snip opening approximately 2 to 3 mm
long is made in the punctum along the tarsal conjunctival
surface. The punctoplasty itself is a relatively simple procedure to
perform. Proper postoperative care is important in maintaining the patency
of the punctoplasty. It is often necessary to have a patient return
two or three times during the first postoperative week to prevent reocclusion
of the fresh punctoplasty incision. Gentle redilation of the
punctoplasty with a lubricated dilator ensures that it heals in an open
position. Patients are instructed to stretch their eyelid laterally
several times a day to stretch open the recent punctoplasty. This simple
one-snip technique with proper postoperative care for 1 week has
a very high success rate.

Traditional two-snip techniques rely on the use of two connecting snips
made along the conjunctival side of the punctum, excising a triangular
wedge of tissue. These two-snip techniques offer little advantage over
a one-snip procedure combined with watchful postoperative care and
redilatation.

Three-snip procedures are potentially destructive to the lacrimal outflow
apparatus and rely on two vertically oriented snips that are connected
at their base by a third snip. We recognize the tendency for the three-snip
procedure to be overaggressive and at present do not recommend
this technique.

In some patients, punctal stenosis may recur despite the implementation
of proper punctoplasty techniques. In these cases, a repeat one-snip
punctoplasty should be combined with silicone tube intubation of the lacrimal
outflow system. The silicone lacrimal tubes serve as internal
splints to maintain patency of the lacrimal punctum. The silicone tubes
are relatively inert and may be left in place several months until the
punctoplasty openings are deemed stable. This combination punctoplasty
technique with silicone tube intubation is also useful for reconstructing
punctal injuries or for lacrimal puncta that have been occluded
surgically and have resulted in symptomatic epiphora.

CANALICULAR SURGERY

Lacerations

As has been emphasized, it is important to repair upper as well as lower
canalicular lacerations. Repair can be delayed for as long as 48 hours
with the use of ice compresses, although prompt repair of these injuries
is ideal.77 Local injections of small quantities of lidocaine with epinephrine and
hyaluronidase (Wydase) at the time of repair can assist in reducing local
tissue edema and maintaining hemostasis. For ease of examination
of the tissues, especially with extensive injuries, general anesthesia
may be preferable. Excessive amounts of local anesthetic should be avoided
because they may distort the tissues. In most cases, surgical loupes (e.g., 3.0 to 3.5× ) magnification are quite adequate to perform
the repair. In selected cases, an operating microscope can be used
to help find the severed ends of the canaliculus.

Internal splinting of the canaliculus with a soft, pliable material is
mandatory to repair the laceration. End-to-end anastomosis of the canaliculi
is ideal with 7-0 or 8-0 Vicryl sutures. It may, however, be quite
difficult or impossible to suture the cut edges for 360 degrees (Fig. 13). The following are our materials of choice for intracanalicular stenting:

Fig. 13. Proper placement of sutures and an internal splint in a lacerated canaliculus.

Crawford lacrimal intubation set with suture78 (JEDMED Instrument Co., 5416 Jedmed Ct., St. Louis, MO 63129-2217; phone 314-845-3770): This
is our canalicular stenting material of choice
for lacerations of the ipsilateral superior and inferior canaliculi. Crawford
probes are threaded through the upper and lower puncta and are
sequentially withdrawn from the distal cut end of each canaliculus. These
olive-tipped probes are then inserted, one at a time, into the proximal
cut end of each respective canaliculus and sequentially threaded
through the lacrimal sac and nasolacrimal duct. This single silicone
loop is the most stable method of repairing simultaneous ipsilateral
upper and lower canalicular laceration injuries.79

Monoka monocanalicular lacrimal intubation system (FCI Ophthalmics, P.O. Box 465, Marshfield
Hills, MA 02051; phone 800-932-4202): These are
our stents of choice for monocanalicular injuries.80 The Mini Monoka stents are recommended for midcanalicular laceration injuries, or
canalicular lacerations located relatively close to the punctum. The
Mini Monoka silicone stent is 40 mm long. The full-length Monoka
stents are recommended for canalicular lacerations located closer
to the lacrimal sac, where our longer Silastic tubing will offer greater
stability. A useful example is the Medium Collarette Monoka stent, which
is 260 mm long. The Monoka stents have an attached, self-retaining
punctal plug that securely holds the distal end of the silicone tubing. The
proximal end of the stent gets placed into the proximal canalicular
laceration. The Mini Monoka is only 40 mm long; thus, it does
not enter the nasolacrimal duct. The full-length Monoka stent is on a
pliable metal probe that gets threaded through the lacrimal sac and nasolacrimal
duct.

The Monoka system has the compelling advantage of applying instrumentation
only to the injured canaliculus. Both the Crawford tubes and the regular-length
Monoka tubes have attached metal probes; these stents require
nasolacrimal duct intubation skills and knowledge of intranasal
anatomy on the part of the surgeon.

In monocanalicular lacerations, pigtail probe instrumentation poses a significant
risk to the opposite canaliculus. This instrumentation system
is recommended for experts only, or under closely supervised conditions.81

Identifying the proximal cut end of the canaliculus (or canaliculi) is
perhaps the most trying experience in canalicular repair. If the laceration
is distal and swelling is minimal, identification generally poses
no problem because the canalicular diameter is fairly large (1 to 1.5 mm). If
the laceration is close to or into the lacrimal sac and swelling
is present, identification may be very difficult because the tissues
are distorted and the membranous conduit is compressed. Allowing tissue
swelling to subside with time, applying ice compresses, and injecting
hyaluronidase solution with massage may restore normal contour and
alignment so that the lacrimal laceration may be identified. If the
opening cannot be identified, irrigation of the opposite canaliculus
with air and flooding the field with water can demonstrate air bubbles
emerging from the laceration site.82 Milky corticosteroid suspensions can also be irrigated through the opposite
canaliculus and subsequently visualized at the laceration opening. Injection
of methylene blue is not advised because it stains the tissues
and may further obscure the anatomy.

Canaliculitis

Most cases of canaliculitis can be cured with vigorous curettage and topical
antibiotic eye drops. The canaliculus is anesthetized with a local
anesthetic infiltrated in the medial portion of the affected eyelid. The
punctum is dilated if needed. Vigorous, repeated curettage of the
canaliculus is performed with small and medium-sized chalazia curettes, which
are advanced through the canaliculus up to the junction of the
lacrimal sac. The repeated curettage maneuvers will withdraw yellow, granular “cementous” material that can be sent for culture
and histopathologic examination. The dilated canaliculus often has
multiple diverticula, thus the need for thorough curettage. Once the canaliculus
has been cleared of all formed material, lavage with 1% tincture
of iodine is performed, followed by treatment with antibiotic eye
drops (e.g., sulfacetamide eye drops). Most cases of canaliculitis can
be cured with this approach. Treatment failure is often due to incomplete
curettage. Difficult, refractory cases of canaliculitis can be
treated with complete surgical marsupialization (i.e., cut open the entire
length of the posterior surface of the canaliculus and openly débride
the canaliculus83).

Lacrimal Duct Anlage

The lacrimal anlage is typically located inferonasal to the medial canthal
angle. Treatment is surgical excision of this congenital fistulous
drainage tract of the lacrimal sac.84 During surgery, a Bowman's lacrimal probe may be placed within the
lacrimal anlage to guide the surgeon. Sharp dissection is performed
around the entire anomalous lacrimal fistula until the base is reached. The
entire lacrimal anlage is then excised. Vicryl sutures (7-0) are
used to close the excised base of the anlage. The remaining subcutaneous
tissues and skin are meticulously closed in layers. In young children, with
patients still under general anesthesia, it is very important
to determine the patency of the lacrimal outflow system and nasolacrimal
duct in its entirety. Irrigation or probing should be used to confirm
its patency. If a distal nasolacrimal duct obstruction exists, intubation
with silicone lacrimal tubes should be performed in young children. It
is not necessary to perform DCR in the treatment of these patients.

Canalicular Tumors

Tumors of the canaliculi are rare and are best treated by complete surgical
excision. Surgeons should consider full-thickness resection of the
eyelid margin along with the affected portion of the canaliculus. Frozen-section
monitoring of the margins should be performed during surgery
to ensure complete excision of any lesion. Full-thickness canalicular
defects can usually be closed by mobilizing the cut edges and internally
splinting the reconstructed canaliculus with silicone lacrimal
tubes.

Common Canalicular Stenosis

A localized stricture of the common internal punctum and segmental closure
of the common canaliculus may follow repeated probing, may occur after
DCR, and may follow inflammations such as herpes simplex and other
inflammatory agents. If the problem is a very localized narrowing of
the common internal punctum, silicone tube intubation can be attempted
without the need for an open surgical procedure. It is a relatively
favorable prognostic sign if the olive tip of a Crawford silicone tube
can be passed through the localized stricture. Silicone lacrimal tubes
are commonly left in position for at least 6 months. They act as an
internal splint to dilate and maintain patency of the common internal
punctum.

In patients with common canalicular obstructions, it is important to determine
whether an underlying nasolacrimal duct obstruction is present
as well. Putterman has described a clever technique of transcutaneous
dacryocystography.85 In this technique, a 25-gauge needle is used percutaneously to introduce
water-soluble contrast dye directly into the lacrimal sac. A conventional
roentgenogram is used to visualize the lacrimal sac and nasolacrimal
duct for pathology. This diagnostic technique bypasses the problem
of an occluded common canaliculus and allows the surgeon to determine
whether concomitant DCR is necessary along with treatment of the common
canalicular obstruction.

If attempted probing of the canaliculi reveals that the segment of occlusion
is quite wide, an open surgical procedure is necessary to attempt
to reconstruct this region. A typical DCR skin incision is used to expose
the lacrimal sac region. The lacrimal sac should be slit open carefully
to expose the occluded common internal punctum. An 00 lacrimal
probe is maintained in the involved canaliculus to help localize the
lateral extent of the problem. In some patients, using this open exposure, it
is possible to core out the area of stenosis; in other patients, a
wider excision of the canaliculus and common internal punctum is
required. After excision, the lateral cut edges of the canaliculus should
be brought medially into the region of the lacrimal sac. Careful microsurgical
closure combined with silicone lacrimal tube intubation of
the system maximizes the chances for ultimate reepithelialization of
an intact membranous lacrimal conduit. The lacrimal sac can be closed
with interrupted 6-0 Vicryl sutures and the skin incision closed according
to the surgeon's usual routine. The silicone tubes remain in
place for approximately 6 months.

As has been mentioned, the wider the area of common canalicular occlusion, the
lower the success rate of the previous surgical procedures. The
prognosis is quite guarded in many of these patients, many of whom ultimately
require a Jones tube procedure for adequate tear elimination.

LACRIMAL SAC SURGERY

Medical Treatment of Acute Dacryocystitis

Only a very localized stricture, such as that which occurs with congenital
dacryostenosis, or a plug or a cast within the membranous conduit
can be cured by probing the lacrimal system. Repeated probing for other
situations is to be condemned and is a common cause of cicatricial canalicular
stenosis. In most situations of acute or chronic dacryocystitis, medical
therapy is initiated before definitive DCR. With dacryocystitis, pressure
over the lacrimal sac may result in reflux of mucopurulent
material from the punctum. Gram stain and culture and sensitivity
testing should be performed on this material to direct the clinician
in the choice of antibiotics.

Acute dacryocystitis is often painful and may be associated with regional
soft tissue cellulitis. Initial therapy should include warm compresses, topical
broad-spectrum antibiotic eye drops, and oralpenicillinase-resistant
antibiotics. For broad-spectrum coverage, we commonly use
Ocuflox eye drops and oral cephalosporin. Elderly or frail patients may
become toxic as a result of acute dacryocystitis. Hospitalization and
intravenous antibiotic treatment (gram-positive, gram-negative, and
anaerobic organism coverage) should be implemented in seriously ill patients
with acute dacryocystitis. As a general rule, acute dacryocystitis
is managed medically without cutaneous drainage of the lacrimal sac. If
the painful lacrimal sac abscess is pointing to a head (impending
spontaneous rupture), however, patients may benefit if the physician “pops” the
lacrimal sac with a #11 blade. This relieves the
pain and pressure and allows expression of purulent material using
a gentle rolling action of cotton-tipped applicators. Broad-spectrum ophthalmic
antibiotic ointment (e.g., Ciloxan) can then be introduced into
the blade drainage slit and used to refill the lacrimal sac with ointment. Oral
antibiotics are used as adjunct treatment for the soft tissue
cellulitis. This maneuver is virtually always curative of the infection
in such cases of acute dacryocystitis. After definitive DCR, it
is distinctly rare for this group of patients to be adversely affected
by a fistula with chronic cutaneous drainage.

We have encountered patients with their fifth or sixth episode of painful
acute dacryocystitis, having refused prior recommendations for DCR. The
lacrimal sac is fibrotic and shrunken and contains sequestered pockets
of purulent material. To supplement oral antibiotic treatment, we
have used regional intramuscular and intralacrimal sac antibiotic injections (e.g., gentamicin, 40 to 80 mg injectable). The injection itself
is quite painful; thus, lidocaine 2% should be infiltrated before
injection of the antibiotic. This local use of intramuscular antibiotics
is very helpful in these difficult-to-treat cases and may spare patients
the need for intravenous therapy.

Both the physician and patient should view the medical management of acute
or chronic dacryocystitis as a temporary, palliative treatment. DCR
is the definitive curative treatment of choice.

Dacryocystectomy for Lacrimal Sac Tumors

Complete excision is the treatment of choice for epithelial tumors of the
lacrimal sac. This excision should include the canaliculi, lacrimal
sac with mass, and an appropriate amount of the nasolacrimal duct. This
surgery can be performed with local anesthesia through a standard DCR
incision. It is mandatory to sever the anterior limb of the medial
canthal tendon to expose fully the fundus of the lacrimal sac. The lacrimal
sac is reflected laterally, and the bone of the lacrimal sac fossa
is inspected for pitting or evidence of tumor invasion. With the surgical
field isolated and exposed, a confirmatory biopsy with frozen-section
analysis is performed. If the biopsy sample indicates a lymphocytic
process (e.g., lymphoma), then no further surgical excision is necessary. Silicone
lacrimal tubes should be intubated into the system in
anticipation of possible postoperative radiation treatment. If the biopsy
reveals inflammation only, then the surgeon proceeds with standard
DCR. Complete dacryocystectomy is indicated for epithelial lacrimal
sac tumors or other nonlymphocytic malignancies. Lacrimal probes are
placed in the canaliculi to guide complete removal of both canaliculi
and the common canaliculus. After free dissection of the canaliculi and
lacrimal sac, the surgeon next exposes and dissects the nasolacrimal
duct. The Linberg “biopsy” technique is useful for removing
the nasolacrimal duct.50 Frozen sections should again be used to verify that the distal nasolacrimal
duct margin is free and clear of tumor. Alternatively, a Caldwell-Luc
surgical exposure can be used to remove larger portions of the nasolacrimal
duct and surrounding bony nasolacrimal canal.

Congenital Nasolacrimal Duct Obstruction

The initial treatment of congenital nasolacrimal duct obstructions is medical. The
parents must be instructed on the proper method of lacrimal
sac massage.86 An index finger is pressed over the common canaliculus to prevent regurgitation
of material from the puncta. The finger is then stroked downward
firmly to increase hydrostatic pressure within the lacrimal sac and
nasolacrimal duct. The parents should perform approximately 10 to 15 strokes
two or three times per day. Significant mucopurulent discharge
is treated with a topical antibiotic ointment such as erythromycin
or broad-spectrum antibiotic eye drops. Medical management can be used
under most circumstances for the first 12 months of life.

Controversy exists concerning the indications and optimal timing for interventional
lacrimal procedures for this problem.87,88 In part, this controversy regarding invasive procedures results from the
high percentage, greater than 90%, of congenital nasolacrimal duct
obstructions that will resolve with conservative medical management during
the first 12 months of life. This controversy also exists due to
the relative ease of office-based probing in 3- to 6-month-old infants
versus the frequent need for hospital-based, general anesthesia probing
in patients greater than 12 months of age versus considerations of
cost effectiveness.88–90 We generally defer probing or silicone tube intubation until a case has
proved refractory to conservative management and the child is 12 months
of age.90 We defer interventional procedures until this age because the success
rate of lacrimal probing or intubation remains extremely high, and we
avoid performing potentially unnecessary procedures prematurely. Most
lacrimal probings in children 12 months of age or older are performed
as an outpatient, hospital-based/ambulatory center procedure using general
anesthesia. Although select 12-month-old children can be restrained
and probed in an office setting, modern general anesthetic techniques
are very safe and a more suitable choice for most of these older children.

Early intervention (i.e., office-based lacrimal probing in children less
than 6 to 8 months old) should be performed in patients with chronic
conjunctivitis, or acute or chronic dacryocystitis. Special social circumstances
that may warrant lacrimal probing at an early age include
chronic mucopurulent discharge (a day-care center may refuse to care for
a child) or inability to afford a hospital-based procedure with general
anesthesia (a 6- to 8-month-old child could be treated with a more
cost-contained probing in an office setting).

Appropriate decisions should be individualized for each patient and his
or her circumstances; the above recommendations are general guidelines
only.

The technique of probing consists of two equally important maneuvers: passage
of the lacrimal probe, and intranasal manipulation and irrigation. A #1 or
smaller Bowman's probe is introduced into the upper or
lower canaliculus after the probe has been adequately lubricated with
an ophthalmic antibiotic ointment. The punctum may require dilation. The
probe is first introduced vertically into the punctum and ampulla
and then rotated horizontally 90 degrees in the same plane, conforming
to the bend in the first portion of the canaliculus. With lateral tension
placed on the lid to prevent kinking of the canaliculus, the probe
is then advanced until it touches against bony firmness, indicating
that it has reached the nasal wall of the lacrimal sac. The probe is
then slightly withdrawn and rotated upward 90 degrees, in the same plane, and
then angled to point 15 degrees posteriorly. It is then advanced
down the nasolacrimal duct, through which it should slide easily (Fig. 14). The probe then meets some resistance at the membranous obstruction at
the distal end of the nasolacrimal duct and may suddenly be felt to “give
way” as it pops the membrane.

Fig. 14. Proper technique of probing. Initial insertion of the probe into the ampulla (1), rotation
to advance into the sac (2), and direction of probe
down the nasolacrimal canal (3).

Attention is then directed to the undersurface of the inferior turbinate, which
has previously been vasoconstricted with combined pediatric oxymetazoline
hydrochloride (Afrin) and pediatric Neo-Synephrine 1/8% nasal
sprays. A thin periosteal elevator is slid under the turbinate and
is rubbed against the probe, which has been passed down through the
nasolacrimal duct. It should be noted that the probe in the lacrimal duct
moves as it is touched, and a metal-on-metal grating is felt and also
heard (“see it, hear it, feel it”). If the turbinate is
compressed over the probe, a twist of the periosteal elevator fractures
the turbinate inward and opens the nasolacrimal duct (Fig. 15). The probe and the periosteal elevator are then withdrawn, and fluorescein-stained
saline is irrigated into the punctum. It should easily travel
down the canaliculus, lacrimal sac, and nasolacrimal duct and can
be aspirated from the nasal cavity with suction apparatus. The patency
of the membranous lacrimal conduit is thus confirmed.

Fig. 15. Intranasal manipulation and fracture inward of the turbinate, if needed, in
probing of congenital dacryostenosis.

In children older than 18 months, surgeons should strongly consider intubation
of the lacrimal system with silicone tubes at the time of probing. The
usually high success rate of nasolacrimal duct probing is diminished
in these older children,22,89 and the use of silicone lacrimal tubes will increase the overall success
rate of the procedure.91,92 The potential drawbacks of silicone tube intubation are considerably less
than the risks and cost of a second procedure under general anesthesia
should the initial probing be unsuccessful. Balloon catheter dilation93 is also a viable treatment option in this older group of children. Silicone
tube lacrimal intubation and balloon catheter dilation both have
an increased success rate in older children compared with lacrimal probing
alone.

INTUBATION WITH SILICONE TUBING

Intubation of the membranous lacrimal outflow system is performed using
soft silicone tubing guided by pliable lacrimal probes. The Crawford
lacrimal intubation set has three distinct advantages. First, the silicone
tubes are factory-glued to metal probes and do not pull apart during
intubation. Second, an olive tip is present on the end of the metal
probe for easy intranasal retrieval with the Crawford hook. Third, an
intraluminal 6-0 silk suture is present for tying the ends of the silicone
tubing together (Fig. 16).94 An alternate choice is Quickert-Dryden tubing, which features a 0.5-mm-diameter
silicone tube that is swaged onto a lacrimal probe.95

Silicone tube intubation can be performed under local or general anesthesia. In
either case, the nasal mucosa and inferior turbinate are vasoconstricted
with combined pediatric oxymetazoline hydrochloride (Afrin) and
pediatric Neo-Synephrine 1/8% nasal sprays. The lacrimal punctum
is gently dilated to allow passage of the Crawford probe and olive tip. In
some patients, a small one-snip procedure is performed to allow
easy entry and passage of the lacrimal probe and silicone tubing. The
probe is lubricated with an ophthalmic antibiotic ointment and passed
first vertically through the lower punctum into the lower canalicular
system. With the lower lid held on stretch to avoid kinking of the canaliculus, the
probe is then rotated 90 degrees so that it is in the horizontal
plane. The probe is then advanced nasally until it enters the
lacrimal sac and encounters the medial orbital wall. It is then rotated 90 degrees
vertically, angled 15 degrees posteriorly, and advanced
down through the nasolacrimal duct. The probe exits from underneath the
inferior turbinate, normally at the junction of the anterior and middle
thirds of the undersurface of the turbinate (Fig. 17). With the aid of a nasal speculum and a fiberoptic headlight, the surgeon
should visualize the olive-tipped probe exiting from under the inferior
turbinate. It is helpful for the surgeon to stand on the patient's
left when visualizing the extreme lateral inferior portion of
the right nasal cavity to locate the lacrimal probe. The surgeon should
engage the Crawford probe with the Crawford hook. Withdrawing the lacrimal
probe slightly should allow the olive tip to engage snugly within
the hook. The entire Crawford probe is then withdrawn from the nose. A
similar maneuver is used to intubate the upper eyelid canaliculus, leading
into the lacrimal sac and nasolacrimal duct. Direct visualization
of the lacrimal probe avoids unnecessary manipulation or “raking” maneuvers
along the nasal mucosa.

Fig. 17. Composite view showing the passage of the two probes.

Visualization of the lacrimal probes is also very helpful when using the
Quickert-Dryden intubation set. With this type of probe, a grooved director
may be slid under the inferior turbinate to allow the probe to
be advanced out of the nose (Fig. 18A). Alternatively, a hemostat can be used to grasp the tip of the probe
and withdraw it from the nose (see Fig. 18B).

Fig. 18. Technique of retrieval of the lacrimal probe from under the inferior turbinate
when using the Quickert-Dryden technique of silicone intubation. A. Use of a grooved director to slide out the tip of the probe. B. Grasping the probe tip with a straight hemostat to pull the probe out.

Crawford tubing has an intraluminal 6-0 silk suture. The metal probes are
cut loose from the distal ends of the silicone tubing. A Crawford stripper
is used to cut the excess silicone tubing that extends beyond
the external naris. The two ends of 6-0 silk suture are then tied together
in multiple knots to secure the silicone tube as a single loop. The
surgeon may suture this loop of silicone tubing to the nasal septum
or lateral alar cartilage internally.96 It is important to avoid tying the silicone tubing under excessive tension, which
could cause erosion through the lacrimal puncta and canaliculi. Silicone
lacrimal tubes are typically left in place for 3 to 6 months97 and can be removed via the interpalpebral fissure in an office setting.98

Experimental studies have shown that the silicone tubing material is inert
and well tolerated by the canaliculi.99 Reports of allergic reactions are rare.100 In most patients, tear flow and lacrimal elimination occur readily around
the silicone tubes down through the lacrimal outflow system. There
is some tendency, however, for mucus to accumulate.

APPROACH TO ACUTE VERSUS CHRONIC EPIPHORA

As emphasized previously, it is critical to rule out causes of hyperlacrimation. Acute
epiphora symp-toms (duration of symptoms less than 6 months) may
be due to a potentially reversible inflammatory blockage of
the nasolacrimal duct (early PANDO). Medical anti-inflammatory treatment
or silicone tube intubation or both may be considered in these cases. Careful
examination for punctal stenosis is also important in patients
with acute onset of symptoms. Patients with chronic epiphora symptoms (duration
of symptoms longer than 12 months) usually have permanent
nasolacrimal duct obstructions (late PANDO). DCR remains the treatment
of choice. Treatment of patients whose epiphora symptoms have persisted
for 6 to 12 months is ambiguous. Specific treatment is always individualized
for each patient.

SILICONE LACRIMAL TUBES: SELECT PATIENTS ONLY

Angrist and Dortzbach have evaluated the role of silicone tube intubation
in adults with PANDO.101 This study compared the treatment results in patients with partial (functional) blockage
of the nasolacrimal duct and total nasolacrimal duct
obstructions.

On attempted irrigation, patients with functional nasolacrimal duct obstructions
typically show reflux of fluid from the opposing punctum and
simultaneous entrance of fluid into the posterior pharynx (i.e., there
is only a “partial” blockage of the nasolacrimal duct). These
patients present with symptoms of chronic epiphora, although they
usually do not have symptoms of chronic infection. In these patients, the
fluorescein dye disappearance test shows delayed dye disappearance. The
Jones I test is negative (no dye retrieved); the Jones II test
is positive (dye is retrieved). A dacryocystogram may confirm anatomic
and functional pathology in the nasolacrimal duct.

Angrist and Dortzbach studied silicone tube intubation in 23 cases of functional
nasolacrimal duct obstruction. Silicone tubes were left in place
approximately 5 months in most cases. With mean follow-up of almost 3 years, the
patients' symptoms of epiphora were successfully alleviated
in 70% to 80% of cases. Early relief of the patients' symptoms with
the silicone tubes in place was a favorable prognostic sign.

By comparison, silicone tube intubation in patients with total anatomic
obstruction of the nasolacrimal duct yielded poor results. Based on pathologic
studies of the nasolacrimal duct, the late fibrotic stages of
PANDO result in total cicatricial obstruction of the nasolacrimal duct. This
pathologic finding would explain the poor treatment results of
simple silicone tube intubation in patients with total nasolacrimal
duct obstructions.

Alternatively, patients who present with functional nasolacrimal duct obstructions
may have inflammatory swelling of the nasolacrimal duct (histopathologically
the early stages of PANDO). This stage of nasolacrimal
duct obstruction is potentially reversible, thus explaining the relatively
high success rate of silicone tube intubation. In these patients, the
silicone tubes are used as an internal splint to prevent permanent
cicatricial closure of the nasolacrimal duct while corticosteroid
eye drops and nasal sprays are used to treat the inflammatory component.

In summary, patients with functional nasolacrimal duct obstructions may
have potentially reversible pathology of the nasolacrimal duct. Treatment
with silicone tube intubation (approximately 6 months) and topical
corticosteroids may achieve a 70% to 80% success rate in alleviating
symptoms of epiphora. Although much experience with silicone tube intubation
in adults is still lacking, this procedure has less morbidity
than conventional DCR. Patients who have functional nasolacrimal duct
obstructions and who do not respond to silicone tube intubation should
be considered for DCR. For patients with total anatomic nasolacrimal
duct obstructions, DCR remains the initial treatment of choice.

DACRYOCYSTORHINOSTOMY

The time-honored surgical treatment for obstruction in the lacrimal sac
and nasolacrimal duct is DCR. The most well-known technique was originally
described by Dupuy-Dutemps and Bourguet102 and popularized in this country by Hallum.103 The operation consists of an external cutaneous incision at the base of
the nose inferior to the canthus, opening of a bony window into the
nasal cavity just anterior to the middle turbinate, and anastomosis of
the lacrimal sac to flaps of nasal mucosa.104 Variations in technique are discussed next and certain steps in the procedure
emphasized. At present, most DCR surgeries are performed as an
outpatient procedure using local anesthesia with intravenous sedation.

Skin Incision

The skin incision is calculated to avoid the angular vessels and provide
adequate exposure. It may be placed close to the canthus, 3 mm from
the inner canthus, over the anterior lacrimal crest; or farther on the
nose, 11 mm from the inner canthus on the other side of the angular vessels (Fig. 19). In reality, angular vessel bleeding is the least troublesome bleeding
encountered and often cannot be avoided regardless of placement of the
incision; it is easily stopped with proper exposure of the vessels. The
incision should be as straight as possible to avoid a bowstring of
the wound.

Fig. 19. Optional skin incision placement for dacryocystorhinostomy or Jones tube
procedure. We favor the one closer to the canthus.

Bony Opening

The bony opening historically was first made with an osteotome and mallet; however, more
precise instruments are now used to make the initial
osteotomy, such as a high-speed rotary drill. After either method of
initial osteotomy, the bony opening must be enlarged from 1.5 to 2 cm
with side-biting rongeurs. The bony opening straddles the anterior lacrimal
crest and should be anteriorly and inferiorly placed and large. Closure
of the intranasal ostium is an important cause of failure of DCR.105 This opening should be made with preservation of nasal mucosa (Fig. 20).

Fig. 20. Placement of dacryocystorhinostomy anterior to the tip of the middle turbinate
as viewed inside of nose (A) and as viewed externally straddling the anterior lacrimal crest (B). The configuration of the sac and nasal mucosal flaps used by the authors
is shown. A large posteriorly hinged nasal mucous membrane flap that
is not sutured but splinted with a catheter and an anteriorly hinged
lacrimal sac flap is used.

Sac and Nasal Mucosal Flaps

The anastomosis between the sac and nasal mucosa has been performed in
a wide variety of ways with H-shaped incisions in the sac and nasal mucosa, making
posterior or anterior flaps. A nasal flap along at least
one area of the ostium seems advisable to cover it with continuous mucous
membrane and prevent fibrous overgrowth of the DCR opening. Anterior
flaps alone with cautery of the posterior edge of the nasal mucous
membrane seem to be the most popular.106,107 Our personal preference is an anterior flap of lacrimal sac mucosa (see Fig. 20A) and a posterior flap of nasal mucosa (see Fig. 20B) with internal splinting. In children, the surgeon must not occlude the
DCR ostium with too much nasal mucous membrane, which would predispose
to closure of the ostium.

Splinting of the Ostium and Canaliculi

Various materials have been proposed to serve as a temporary internal splint
of the surgically created DCR fistula during the healing process
to ensure its patency. The most popular are gauze or umbilical tape saturated
with antibiotic cortisone ointment or a French rubber catheter.108 Either seems satisfactory, but the catheter is easier to remove in 2 weeks
than the packing. Neither the packing nor the catheter ensures the
proper alignment of the common internal punctum with the newly created
fistula into the nose. Intubation of the canalicular system with silicone
tubing using the Crawford tubes in addition to the other splinting
material has been our practice.109 This is performed in an identical manner as described previously, except
that the probes, after being introduced through the canalicular system
and common internal punctum, are brought out through the DCR skin
incision. The probes are excised from the tubing, and the tubing is then
reinserted into the nasal cavity. A straight hemostat inserted through
the nostril grasps the tubes and extracts them. The tubes are tied
into a single loop with the intraluminal 6-0 silk suture. The silicone
tubes are left in place 3 to 6 months after surgery.

Complications

INTRANASAL PATHOLOGY.

An enlarged or diseased turbinate may extend and impede the DCR opening, which
is usually just anterior to the tip of the turbinate; in such
cases, the tip must be excised. Large intranasal polyps may also present
an obstructive problem and must be removed. A high deviation of the
intranasal septum may reduce the working space. However, only if the
septum is against the lateral wall of the nose, as may occur in posttraumatic
cases, does it preclude the success of the DCR. Biopsy samples
should be taken of unusual tissue and sent for histologic examination
to rule out a neoplastic problem.

ANTERIORLY PLACED ETHMOIDAL AIR CELLS.

In many patients who undergo DCR, the ethmoidal air cells have eroded into
the lacrimal bone between the sac and the intranasal cavity.110 They are a source of intraoperative bleeding and may be a cause of postoperative
closure if the patient develops ethmoiditis. If encountered, they
should be completely removed from the area and stripped of their
mucosal lining. Some cases of unusually large air cells between the
sac and the intranasal cavity have been encountered; these have required
a double osteotomy to reach the intranasal cavity, one into the air
cells and the second from the air cells into the nose. The fact that
the intranasal cavity has indeed been reached should be verified by passage
of a probe or catheter through the nostril into the DCR opening
into the sac area.

CONTRACTURE OF THE LACRIMAL SAC.

After long-standing infection or trauma, the sac may be severely contracted
so that when it is opened, it is little more than a rim of mucous
membrane around the entrance of the canaliculi at the common internal
punctum. The chance of establishing a permanent DCR fistula into the
nose is obviously lower in these cases. However, success may be obtained
in many cases with internal splinting with silicone tubes, as previously
described, and a rubber catheter, which is left in position for 3 weeks. The
silicone tubing may be left in place for several months in
these cases.

INTRAOPERATIVE HEMORRHAGE.

Minor but persistent hemorrhage that can be easily controlled may occur
from the angular vessels. More severe, frustrating, and not as easily
controlled hemorrhage can occur from the ethmoidal air cells and the
turbinates. Proper positioning and an adequate amount of intranasal packing
for vasoconstriction with 4% cocaine111 on umbilical tape in the intranasal cavity before the operation begins
are mandatory. The packing should be placed to cover the lateral wall
of the nose anterior to the middle turbinate and the turbinate area itself. All
aspirin should be discontinued for 2 weeks before surgery because
of its effect on platelet function. If general anesthesia is used, enflurane
in the anesthesia is preferable to halothane because of
its lack of vasodilation. Injection of the lacrimal sac area with 1:100,000 epinephrine
and hyaluronidase is also helpful.

Endonasal Dacryocystorhinostomy

Intranasal approaches to DCR surgery were described more than 100 years
ago. The more recent use of nasal endoscopy techniques combined with
endonasal laser technology over the past 10 to 15 years has stimulated
a renewed interest in this surgical approach to dacryocystorhinostomy.112–115

The modern endonasal DCR procedure may be performed using local anesthesia
with intravenous sedation, or general anesthesia. A lubricated, 20-gauge
fiberoptic light pipe is passed through either the superior or
inferior canaliculus. Previously placed nasal packing is removed. The
transillumination site of the fiberoptic light source is localized endonasally
at the intended rhinostomy site. Under video endoscopic guidance, a
high-energy (e.g., 5 to 15 W) argon surgical laser is used to ablate
the nasal mucosa overlying the lacrimal sac and proximal nasolacrimal
duct. The endocanalicular fiberoptic light pipe is advanced so as
to break the thin bones of the nasolacrimal canal and to tent the lacrimal
sac from within. Further laser ablation of these remaining tissues
is performed to complete the DCR opening. Silicone lacrimal intubation
is then performed, with the silicone tubes being secured intranasally.

The advantages of the endonasal DCR procedure include avoidance of a cutaneous
incision and scar, less postoperative soft tissue bruising and
swelling, and possibly a more ready patient acceptance of the procedure
due to the absence of a skin incision, the use of “laser technology,” and
so forth.116

The main disadvantage of the endonasal DCR procedure is the approximately 75% success
rate compared with an established success rate of 90% or
greater with external DCR surgery.117 Additionally, the endonasal procedure would not be appropriate for patients
with lacrimal sac neoplasms, dacryolithiasis, or a severely cicatrized
lacrimal sac.118 Endonasal DCR would not be feasible in patients with nasal severed altered
nasolacrimal anatomy (e.g., posttraumatic). Intraoperative difficulty
with nasal or regional bony anatomy can necessitate intraoperative
conversion from the endonasal technique to an external DCR (13% of the
time in a study of 53 attempted endonasal DCR procedures119).

At present, the standard, external DCR procedure is favored because it
offers the highest success rate and the cutaneous scar is rarely a problem.

Transcanalicular Dacryocystorhinostomy

Transcanalicular DCR surgery has been performed experimentally and for
revision of failed DCR surgeries. Experimental studies120,121 in human cadavers used a transcanalicular YAG laser technique to create
a DCR fistula between the lacrimal sac and nasal cavity. The clinical
study of DCR revisions in 11 patients used a transcanalicular neodymium:YAG
laser with a success rate of 46%, results that compare relatively
poorly to more conventional external DCR revision techniques.122 Transcanalicular laser techniques for the treatment of canalicular stenosis, PANDO, and
DCR reoperations remain experimental at this time.

Repeat Dacryocystorhinostomy

The two most common causes of DCR failure are common canalicular obstruction
and obstruction at the rhinostomy site.123 Lacrimal outflow irrigation often can differentiate between these two
problems. A common canalicular blockage typically elicits pain on attempted
irrigation, as well as direct regurgitation of fluid from the canaliculus
being irrigated. If the common canaliculus is patent and the
rhinostomy site is blocked, fluid irrigated through the lower lid canaliculus
collects in the residual lacrimal sac and refluxes from the upper
lid punctum. A dacryocystogram is often helpful in the evaluation
of DCR failures.124 This contrast roentgenogram localizes the obstruction and possibly reveals
other pathology such as dacryoliths or sequestered ectasias of the
lacrimal sac.

During repeat DCR, the anterior crus of the medial canthal tendon is incised
to gain full exposure of the fundus of the lacrimal sac. The surgeon
should dissect anterior to the prior rhinostomy site to expose virgin
nasal mucosa. This virgin nasal mucosa is then incised in a way that
affords inspection of the internal aspects of the previous rhinostomy
site. Bone, scar tissue, ethmoidal air cells, dacryoliths, or an adherent
turbinate may be revealed as the cause of the initial DCR failure. In
some patients, the intranasal ostium may simply have closed. Ina
series of 22 DCRs, Linberg and colleaguesdocumented that surgically
created ostia (average11.84 mm in diameter) undergo dramatic narrowing
during the first few months of healing (average1.80 mm in diameter after
surgery).105 Thus, complete ostium closure remains a frequent concern among DCR failures.

Surgical treatment is directed toward the cause of initial failure. It
may include enlargement of the rhinostomy (ostium) site, extranasal ethmoidectomy, partial
middle turbinectomy, and complete removal and curettage
of dacryoliths. The lacrimal sac should be slit open from its fundus
to the beginning of the nasolacrimal duct. Lubricated 00 Bowman's
probes can identify the location of a common canalicular obstruction
when present. In these cases, with a probe in position, an incision
is made lateral to the site of the obstruction. Intervening canalicular
scar tissue is excised, and healthy canalicular tissue is meticulously
sutured to the lacrimal sac mucosa. Silicone stents are used in
all cases involving common canalicular reconstruction.

Mitomycin C inhibits fibroblast activity during wound healing and has well-established
uses in ophthalmic surgery.125–127 More recently, its use has been investigated in DCR surgery128,129 and for its effect on nasal mucosal fibroblasts.130 More long-term studies are needed, but adjunctive treatment with mitomycin
C offers the potential of increasing DCR and reoperation DCR success
rates in select cases by combating the mechanism of distal canalicular
and osteotomy fibrosis and scarring. The effect of fibrovascular
suppression appears to be dependent on the concentration of the drug, the
duration of topical application, and other factors such as surrounding
tissue inflammation and vascularity. More studies are needed in this
area.

Finally, anterior and posterior flaps of lacrimal sac and nasal mucosa
are carefully anastomosed. By incision of the anterior crus of the medial
canthal tendon (performed earlier in the reoperation), good flaps
can be fashioned both superior and inferior to the common canaliculus. In
reoperation DCRs, the lacrimal sac or nasal mucosa or both may be
deficient. Full-thickness buccal mucous membrane grafts may be used to
create flaps in these especially difficult cases.

In DCR failures due to distal rhinostomy site obstructions, Berlin and
associates have reported success in reoperations guided by nasal endoscopy.131 Post-DCR nasal endoscopy may reveal adhesions between the rhinostomy site
and nasal septum or turbinates. These cases are treated by intranasal
lysis of synechiae. Postoperative intranasal endoscopy may reveal
pyogenic granulomas occluding the rhinostomy site; these can be treated
with corticosteroid nasal sprays.

Evaluation of the DCR failure requires the same degree of thoroughness
that one would use to evaluate any challenging lacrimal problem. As always, clinicians
must correctly localize the obstruction before implementing
treatment. A dacryocystogram is a very useful diagnostic tool in
evaluating DCR failures. Reoperations should adhere to sound surgical
principles such as opening the lacrimal sac completely from fundus to
nasolacrimal duct and forming meticulously sutured anterior and posterior
flaps. Nasal endoscopy has great promise as a valuable diagnostic
and therapeutic instrument in certain DCR failures.131,132

JONES TUBE PROCEDURE (CONJUNCTIVODACRYOCYSTORHINOSTOMY)

A bypass procedure for tear elimination is indicated when the lacrimal
canaliculi have been destroyed or the remnants of canaliculi cannot be
anastomosed satisfactorily with the intranasal cavity to establish tear
drainage. It is also indicated in some cases in which the eyelids are
totally paralyzed or tethered by scar tissue so that the pumping action
of the canaliculus is absent. A small Pyrex glass tube is placed
to drain the tears from the lacrimal lake into the nose, and its mechanism
is strictly that of gravity drainage, although some lid movements
must be present to move the tears into the lake area. Materials other
than glass have been used as the bypass conduit; however, these are not
as effective because they are hydrophobic and repel a smooth flow of
tears.133 Because no canalicular system has ever been successfully reconstructed
even on a short-term basis using skin grafts, mucous membrane grafts, or
vein grafts, this is the best available procedure. If one follows
Jones' original technique, as described elsewhere,134 the success rate is quite high in adults135,136 and acceptable in children.

A DCR-type exposure with a bony opening is made. The opening may be smaller
and inferiorly placed. In general, flaps are not required and in
many cases are impossible because of destruction of the anatomy in that
area from the disease process. We prefer to omit flaps to create more
stability in the tube. After careful excision of the caruncle, a soft
tissue tract is made from an area of the excised caruncle to the bony
opening at an angle so that the flange of the Pyrex tube will be properly
placed behind the eyelids in the canthal angle. The opening of the
Pyrex tube in the lacrimal lake should be placed so that it is rotated
slightly outward and the tube itself angled downward 45 degrees so
that the tear flow enters the tube properly. A series of tubes with different
lengths and curvature are then placed through the tract to ensure
that the position of the flange at the canthal angle is proper and
placed well within the lacrimal lake area and that the tube is angled
downward, not horizontally, so that gravity removes the tears. A wide
variety of lengths and configurations of Pyrex tubes can be obtained. Evaluation
of the length of the tube is important, and the proper length
is one in which the tip of the tube extends far enough into the nasal
cavity to clear the lateral wall but not far enough to abut the intranasal
septum. Placing the glass tube at the initial surgery and fixating
it with a suture allow more precise placement and eliminate the
need for the temporary polyethylene tube used in the original technique. Various
lengths and shapes of tubes must be available to a surgeon
in the operating room to do this. We use a tube configuration that is
angled forward midway down the tube to avoid the tip of the middle turbinate. Fixation
of the glass tube is accomplished with a suture that
is left in position for 2 weeks. This is a nonabsorbable suture that
is threaded through and looped around the tube. The suture is knotted
at the edge of the flange and is then introduced into the eyelid to fixate
the tube.137,138 Special tubes may be obtained with a hole in the flange for a fixating
suture.

The intranasal anatomy is far more critical with a Jones tube procedure
than with DCR. Adequate space must be available in the upper nasal cavity
without significant deviation of the intranasal septum. Polyps or
an enlarged middle turbinate tip may need excision. After an initial
period of 2 to 3 months, the passageway may loosen and a different length
of glass tube may be inserted if encroachment of the intranasal septum
or turbinate occurs. Careful intranasal monitoring of the end of
the glass tube is necessary to ensure drainage of tears and to avoid intranasal
irritation and bleeding. We have been unable to get our patients
to remove the tube entirely at the end of several months and keep
the soft tissue fistula patent by home dilation with a probe, although
Jones has had success with this. Most patients can retain the tubes
quite successfully for an indefinite period of time.

Complications of Jones tubes include early and late tube migration or extrusion,136 obstruction with failure of tear drainage,139 periocular discomfort, and overall patient dissatisfaction with the procedure.140 Other less common reports of complications include tube breakage,141 systemic toxicity from phospholine iodine,142 and episcleral irritation and lid inflammation associated with Jones tube
migration.143